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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E Weber Avenue 3d Floor Stockton•CA 95202-2708 r t 1 (209)468-3420•Far:(209)464-0138 • Web:www.co.san-joaquin_ca.us/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: 2 "F / PA#: D(,r0 3// y F . ��~ REPORT DATE: 2 7-/0 (� S - Imuf Insufficiee nt ic I � San Joaquin County Development Title Chapter 9-905,Section 9-905.12 S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION J4 ❑ 1.1 Description of site(report must address all parcels),including current and/or proposed zoning information. ❑ 1.2 Description of proposed�development.rJlo ❑ 1.3 Parcel location map. /,Ifen- A 0 n ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures,drives,wells,septic systems, large trees, L�r pastures,pools,natural drainage courses,ponds,waterways,etc.) 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION ❑ ❑ 2.1 Discussion of past,present and proposed future uses at the site to assess potential problems. (Example sources of information:current and/or previous property owners,historical maps,insurance maps, previous land use applications,etc.) 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION ❑ 3.1 Discussions of the methods used to research and investigate the potential or known above and belowground P1sources of contamination at the project site. (Examples: Database search, EHD records search,agricultural chemical application search,site reconnaissance and survey,etc.) ❑/ ❑ 3.2 Description of all past on-site potential and/or known above and below ground sources of contamination identified at the project site. (Examples: Agricultural chemical handfing/sterage/use,aboveground/underground tanks, septic systems,injection wells,unsealed wells, pondsAagoons,vehiclelmachine repair/painting,buried or 0 stockpiled solid waste,etc.) ❑ 3.3 Description of all current on-site potential and/or known above and below ground sources of contamination identified at the project site(see examples above). ❑ 3.4 Description of all past off-site potential and/or known above and below ground sources of contamination identified nr, in the area of the project site that has or may impact the project site. (Examples: Close proximity to a former Y landfill/former gasoline station,in area of known DBCP/Nitrate groundwater impact, etc.) ❑ 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination .>. identified in the area of the project site. 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION ❑ ❑ 4.1 Evaluation of each potential and/or known source of contamination identified(n the above section)for any real and/or potential threat to human health and the environment. This evaluation should take into consideration the proposed future uses of the project parcel. , 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend further action to mitigate or abate any real or potential threats identified. Recommendations may include additional site assessment(i.e.collection of soiltwaler samples)and/or mifigative measures(.e.,dean up of surface wastes). AT recommendations for future work must include a time frame for implementation. ❑ 5.2 The report was inclusive(.e.an information referenced was included in this report-report should not reference other reports). e, 7 W.1m ❑ 5.3 The report was signed,dated and stamped by a qualified environmental professional. N I ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. �( ❑ 5.5 The attachmentslappendices contain sufficient documentation to support claims made in report. Reviewed By:��Lc fJ✓�7 Reviewed Date: 411 /U� EHD 260'--001 Page I of 2 surf>c&Sub checklist 7/I M003